Choose Wisely: Studies Show Increased Risk of Cesarean Linked to Choice of Doctor

By Jacqueline Levine

The cesarean rate in the United States has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”; the report cites the current rate as 31.3%. That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization and other organizations that promote and support optimal maternity care have been making that case for a long time.

Most recently, the American Congress of Obstetricians and Gynecologists (ACOG) has come out with a report entitled “Safe Prevention of the Primary Cesarean Delivery,” with guidelines meant to prevent a first-time c-section. The study calls for revisiting the list of the common indications for cesarean. The various rationales for cesarean have held sway in maternity care for years. These new guidelines can be seen as an admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the ideal health of women and babies.

Added to this news are two studies that reveal additional factors that can affect a woman's chance of having a cesarean. News from the American College of Obstetricians and Gynecologists’ (ACOG) 57th Annual Clinical Meeting, as reported in Medscape Today (Medscape Medical News, May 12, 2009), discussed an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates.” The following is a direct quote (bold emphasis is mine):

“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out. Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery. Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association betweenprofessional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean(s) delivery. Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem," "We all anticipated that defensive medicine might be a reaction to litigation, and this paperdemonstrates that that is indeed the case," "So don't just blame the doctor for doing a C-section, recognize that there's probably a reason that [he or she is] doing it. And that fear of litigation is the reason," Dr. Barnhart concluded.”

The study implies that what’s being done in the way of care might indeed be for the welfare of obstetricians who practice defensive medicine, and may not be for the best welfare of the woman in his care. The results of this study are not addressed in the recently released ACOG guidelines to eliminate the overuse of c-section, but it's helpful to acknowledge the possible affect of malpractice insurance on women's birth options.

We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. A doctor who picks up a scalpel and performs surgery for defensive reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship.

The other study addresses how an obstetrician's personality affects your risk of having a cesarean. The article, “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality,” discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal ofObstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation.

The results of the study are very concise (emphasis mine):

“Obstetricians were asked to complete a validated survey that measures ‘trait anxiety’ which is stable and enduring… The obstetricians with the least anxiety had the lowest emergency cesarean rates. The obstetricians with the mostanxiety had the highestrates.”

These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean -- factors that have nothing to do with a mother’s or baby’s actual health status. The more we know about what influences doctors in the decisions they make about our care, the better our ability to recognize and request best-evidence care for ourselves and our babies. And so the question becomes, how can a birthing woman understand and avoid the influence of lesser-known factors on her chances of avoiding cesarean?

As our own best advocates, we must seek out the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers. Before deciding on a caregiver , it's of critical importance to become familiar with best-evidence, optimal maternity care, so that you're able to question her/him about all the health care practices that will affect labor and birth. Knowing the facts about normal, healthy birth and conservative reasons for c-section based on our genuine health status help you make informed choices about your care.

Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website www.thebirthsurvey.com. Question your prospective OB or midwife about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care. If you perceive a defensive posture about his stats, or an air of reluctance to tell you what you want to know, consider it a red flag warning and seek a new caregiver for optimal care.

Jacqueline Levine, BA, LCCE, FACCE, CD(DONA), CLC has been a DONA doula and lactation counselor for 10 years, a Lamaze educator for twelve years, and a WIC educator. She teaches Lamaze childbirth education at Planned Parenthood of Nassau County, where she volunteers birth doula services to the clients of Planned Parenthood, an underserved population. She won the Lamaze Community Outreach Award for these services to the community, and she has taught and supported pregnant teens in local high schools.

She’s been a contributor to Science and Sensibility, the Lamaze research blog, since 2009, and writes for BreastfeedingUSA, the online peer-to-peer breastfeeding site as well. Some of her articles for breastfeeding teens have been on the US Breastfeeding Committee site, and she is a guest lecturer in the Sociology Department of CW Post College of LIU, teaching a class in the History of Childbirth in the United States, as well as breastfeeding classes for DONA doula certification that stresses best-evidence care for mothers and newborns.

She is mother of three and grandmother of five, and came to the world of birth after she retired from a career as artist and designer in the Garment Center in NYC.